and the os uteri being very small and rigid. The author determined to attempt its reduction by continuous pressure, with the intention of dilating or developing the os and cervix uteri. With this object the right hand was passed into the vagina night and morning, and the uterus squeezed and moulded for about ten minutes at a time. Chloroform, which had been found so useful in cases of inversion of shorter standing, was not used, because of the feeble state of the heart and circulation, and the comparative absence of pain. In the intervals between these manipulations, in which the author was assisted by Dr. Vernon, the vagina was distended, and firm pressure exerted upwards by a large air pessary. These means gradually dilated the os uteri to such an extent as to allow of the partial return of the uterus, and on the eighth day from the commencement, complete reinversion took place. The subsequent recovery of the patient was perfect. She has since menstruated regularly, and is in excellent health. The author combats the prevailing notion as to the immobility and unyielding condition of the os uteri in long standing cases of inversion, alluding to the readiness with which the uterus increases, diminishes, and alters in size, under appropriate stimuli. No amount of force will suddenly reduce a case of chronic inversion, but he believes that by air or fluid pressure, so as to convert the fundus and body of the uterus into a wedge, the os uteri may be slowly enlarged in any case, so as to admit of reinversion. Since the presentation of the paper, the author has been informed that the patient is now in the fifth month of pregnancy. The paper concluded by a reference to other conditions, in which air or fluid pressure had been of service, such as the arrest of flooding in abortion, placenta prævia, the expansion of the pelvis in cases of high deformity from mollities ossium, and the induction of premature labor. ART. 135.-Obstinate Menorrhagia arrested by Iodine Injections. By Dr. SAVAGE.

(Lancet, Dec. 5, 1857.)

Dr. Savage relates two cases of obstinate menorrhagia, in which tincture of iodine was injected into the uterine cavity with the most successful results. In one of these a strong solution of tannin and alum had been injected before having recourse to the iodine, and the bleeding had been arrested for a time. Three days before injecting the iodine, the interior of the uterus was scraped out by Recamier's curette (an operation which gave rise to no pain), and the injection was twice repeated, at intervals of three days, when the hemorrhage had ceased entirely. Each time three drachms of the officinal tincture of iodine were used. In the other case the injection consisted of two ounces of the same tincture and an equal quantity of water, and the recovery was equally rapid and perfect. Before resorting to the injection, Dr. Savage dilated the cervix uteri freely, and this he considers to be an important part of the treatment.

ART. 136.-Obstinate Menorrhagia cured by Injection of Tincture of Steel. By Dr. BRESLAU, of Munich.

(Monatsch. für Geburtskunde, Oct., 1857; and Med.-Chir. Review, Jan., 1858.) "Dr. Breslau's case of injection of liquor ferri sesquichlorati shows the efficacy of this treatment in certain cases of excessive uterine hemorrhage. A woman, forty-five years old, had worn a pessary for a long time, which she had given up on account of pain and hemorrhages. Examined, there were found five grape-shaped polypi around the os uteri, with ulceration. These were removed by Siebold's scissors, and potassa fusa applied to the ulcerations. The hemorrhages remitted somewhat. The uterus was, however, entirely bent upon itself, and the menses returned in great excess. The cavity of the uterus was somewhat enlarged. The return of the menorrhagia reduced the patient to an extreme degree of anæmia. Ergot of rye failed to effect any contraction of uterus or arrest of flooding. Two possible conditions presented themselves to Dr. Breslau. 1st. The five polypi attached to the cervix favored the presumption that there existed a similar warty hypertrophy of the lining membrane of the uterus. 2d. There might be a destructive ulcerative process of a malignant character going on in the same structure. In the first case, the

curette of Récamier seemed indicated, in order to scrape the uterine membrane clean from the presumed excrescences. In the second case, it seemed necessary to bring a caustic and styptic agent in direct contact with the diseased membrane. To answer this latter indication, he selected the liquor ferri sesquichlorati of the Bavarian Pharmacopoeia. Having first straightened the retroflected uterus by the sound, and inserted an elastic catheter as far as the fundus, he injected one ounce and a half of the liquor ferri, diluted with an equal quantity of water. The injected fluid was retained in the uterine cavity for a minute and a half by the pressure of the fingers at the os around the catheter. During the operation, the patient felt a dull labor-like pain, which lasted for two hours. The hemorrhage, which had hitherto been unintermitting, now suddenly stopped, and was not renewed. After some days, brown, crumbling clots were discharged, but no fluid blood. Seven months afterwards there had been no return of menorrhagia. The patient menstruated regularly every twenty-one to twenty-four days; and, through internal administration of steel and quinine, recovered robust health."

ART. 137.-Cupping the Interior of the Uterus. By Dr. HORATIO R. STORER.

(American Journal of Medical Science, Jan., 1858.)

This operation was conceived and first practised by Dr. Simpson, of Edinburgh, but as yet it does not appear to have been made public in any

manner.

"The instrument used," says Dr. Storer, "identical save in coupling with one made for me at Edinburgh, in 1854, and now also exhibited, is from the hands of Messrs. Codman and Co., of Tremont street.

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Its construction is sufficiently simple. An air-pump, small but powerful, and a perforated tube, itself of sufficient calibre to contain several drachms of blood, yet not too large to enter the os and cervix uteri; its orifices of a size to escape easy clogging with mucus or clots of blood, and yet too small for extensive laceration, or hernia of the mucous coat, and its axis curved to correspond with those of the uterus and vagina. Its passing to a sufficient depth within the uterine cavity is ensured, its entering too far is prevented, by a ring of gutta percha, bevelled above for more perfect closure of the os, and adaptable to any case by remoulding. The exact position of this ring is to be determined by previous careful use of the uterine sound. Like that of the intra-uterine pessary, the point of the stem should almost, but not quite, reach the fundus uteri. By this precaution, danger is avoided, and a much more thorough effect rendered probable.

"To the manner of coupling I am inclined to attach some importance. In the Edinburgh instrument, the pump is screwed to the upper portion of the lower tube, while in the other I have joined them by caoutchouc pipe. The liability of a screw-thread to become worn, and the less chance of violence in case the piston should play stiffly, if the coupling, while perfectly tight and fitting, were yet elastic and flexible, occasioned this modification.

"I have used the cup in other cases than those reported, in every instance with the effect of inducing the sanguineous discharge, and I have never seen from it any permanently disagreeable result. Its power upon the nervous system is, however, at times so decided, that its use should be with care. In one case, where the introduction of the instrument had been painless, the first play of the piston occasioned instant and alarmingly profound syncope.

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To the microscopist, this instrument might frequently prove of use, by affording an easy means of procuring healthy or diseased secretions directly from the cavity of the uterus.

"Whether in practice the cup will be found to answer any other indication than that for amenorrhoea already instanced, as for relieving ordinary congestive and inflammatory attacks, either of the uterus itself, Fallopian tubes, or ovaries, remains yet to be seen."

CASE 1.-Catharine -, of Roxbury, æt. 30, and unmarried, applied for treatment at the Eustis Street Dispensary, February 2d, 1857.

Catamenia reported as entirely absent for seventeen years; having commenced at 12, continued regular for one year, and then on her taking cold, permanently ceased. A general leprous eruption, which immediately followed this suppression, has been constantly present since, disfiguring the patient and otherwise causing her much discomfort.

Somewhat dyspeptic and anæmic; costiveness; addicted to headache, flatulence, nausea. Öld ulceration of tonsils. Vaginal leucorrhoea.

She was at first mainly treated for the disease of the skin. The diet was carefully regulated and the bowels kept moderately open. Iodide of sulphur was used locally, Fowler's solution by mouth till specific effect; in vain.

The protoiodide of mercury was then given, though all syphilitic taint had been denied. It was pushed till great irritability of the bowels was produced, though it had been combined with an opiate; patient not improved. The mercurial was subsequently resumed and continued till April 1st, when the gums were sore. It was then stopped, and the arsenic again commenced.

In the mean time, the catamenial disturbance had not been lost sight of. There was never present any decided menstrual molimen; it was therefore impossible, save empirically, to time the attempts at assisting nature. There was, it is true, pain in the head and back, but irregular and uncertain, while the leucorrhoea presented no monthly or periodic increase.

On March 14th, alteratives and tonics having been given for six weeks, with aloetic purgatives, hot hip-baths, &c. &c., from time to time, without benefit either to skin or uterine system, a vaginal examination was made. The abdomen had been previously ascertained to be free from enlargement or tenderness. The uterus was found depressed and slightly retroverted; its cervix elongated, but of small diameter; os almost impervious. The sound entered with difficulty about two inches.

Sinapisms to the breasts were now ordered, in addition to and with the emmenagogues already employed.

March 19th.-No effect produced other than that patient has so well tested the mustard as to have blistered both breasts. These abrasions were treated by collodion.

April 1st.-A succession of flexible metallic bougies, an eighth to a fourth of an inch in diameter, were passed through the cervix uteri.

4th. A galvanic steam-pessary, an eighth of an inch in diameter, introduced into the cavity of the uterus.

12th.-Pessary still worn. Patient cupped at and below sacrum.

May 8th.-No effect having been produced, the intra uterine air-pump hereafter to be described was applied, and by it 3ss of blood drawn from the interior of the uterus. This was early in the morning; the discharge continued throughout that day and night.

June 6th.-Patient reports herself as in all respects better. Air-pump again applied, and flow again produced; this time more readily than at first.

When last seen, early in July, the patient had still further improved in general health and spirits, while her skin had begun to assume a more natural hue and feel.

CASE 2.-Margaret

æt. 25, from Winchester, entered the Lying-inHospital, under my charge, October 10th, 1856.

Patient unmarried. Catamenia never appeared till her 21st year; discharge always very scanty, ceasing and reappearing at intervals during one or two days, and always attended with excessive local pain which continued throughout the period. Recurrence of menses irregular, frequently passing five or six weeks, as is at present the case.

Dyspeptic, anæmic, hysterical; for which general treatment, hydrocyanic acid, cannabis indica, &c. &c.

Upon examination, some tenderness of abdomen, which was retracted. To the touch, the os seemed almost impervious; cervix somewhat elongated; uterus depressed. For this a ring pessary had formerly been introduced with some relief. Ordered aloes, hot hip-bath, sinapisms to breasts.

October 12th.-No appearance of menses. Uterine sound introduced two inches, and followed by smallest sized galvanic stem-pessary.

The next morning the menstrual discharge was established, not very abundantly, but comparatively more so than ever before, and with very much less pain. It continued for two days.

22d.-To-day a series of four metallic bougies passed; all, even the largest, with ease.

November 15.-Bougies repeated. Yesterday and the day previous, galvanic pessary. To-day menstruates as before, and almost without pain.

The flow continued two days; and then, on November 17th, patient discharged from the hospital, much relieved.

In the spring of the present year, I was again consulted by this patient. The improvement above noted had continued for some time, and then had yielded to a recurrence of all the former distress. I therefore applied the air pump, the menses being overdue, and produced a free sanguineous discharge. This was several times repeated, at the proper intervals, in July for the last time, always with relief to the usual symptoms, and apparently with permanent benefit to the general health.

ART. 138.-Autopsy of a Woman whose Uterus had been removed thirty years previously. By Dr. G. S. GODDARD.

(Nederlandsch Lancet, and Dublin Medical Press, March 3, 1858.)

In the anatomical collection at Rotterdam a remarkable specimen is preserved; it is the uterus of a woman, in whom inversion of that organ had occurred in the year 1821, probably in consequence of forcible separation and removal of the placenta. After repeated but fruitless efforts to reduce the uterus, and when the symptoms had assumed a more and more threatening aspect, the part was tied by Surgeon Nortier thirteen days after delivery; and eight days subsequently the tumor below the ligature was removed with a pair of scissors; in the evening of the following day the ligature lay loose in the vagina, and exhibited the small opening through which the pedicle had passed. A month later the woman had quite recovered, menstruation did not recur, and the sexual passion was wholly extinguished. In the preparation the uterus is seen, of the size of the head of a child at full term, with an internal rough, flocculent surface, which, at the right side, in the neighborhood of the fundus uteri (where the placenta was attached), has an opening with uneven edges, of about an inch and a fifth in circumference. Less extensive on the under side, this sacciform body ends with an opening of about two and a third inches. On the left side of the fundus portions of the Fallopian tube and of the round ligament, both, as well as the uterus, still enlarged, are seen; while on the right side the round ligament appears to be partly destroyed, and a much larger portion of the Fallopian tube is evidently also destroyed in its whole length. The woman died in 1850, in consequence of an acute disease, in which the genital organs were not involved. On opening the body the internal genitals, on a superficial inspection, presented a tolerably natural appearance, except that the right broad ligament was rather tense, giving rise to a degree of obliquity; there was a great accumulation of fat in the connective tissue around the vagina and between the lamina of the broad ligaments, in which no cicatrices, but only modified plaiting, were to be seen. The folds of the mucous membrane of the vagina were very strong and irregular; the vagina itself was much shorter than usual. Of the uterus only the cervix remained; the cavity of the latter was scarcely large enough to contain a lemon pippin, was very pointed, and was about three inches in length; the palmæ plicata were very strongly marked; the walls, which were thicker than usual, terminated as cut off; on the surface looking towards the cavity, was a white, firm, cellular, intervening substance, a couple of lines in length, and particularly dense on the right side, which as. cicatrix had filled the space left open in the operation, and as well as the truncated substance of the uterus, had become covered with peritoneum. The free extremities of the Fallopian tubes were normal; each terminated in a cul de sac, the right was shorter than the left, and with the ovary was drawn strongly downward by a fold of peritoneum. The round ligaments were in great part deficient on both sides; the right was the shorter, and was surrounded with

The ova

much connective tissue. The left could be followed a little further. ries were more atrophied than even the woman's time of life should lead one to expect; the ligament of the right ovary was very small; that of the left still in a great measure existed. On either side there was one of those pediculated hydatid-shaped bodies, which Kobelt and Follin regard as remnants of the ductis Mulleri in the corpus Wolfianum; the right possessed a short and broad, and the left, on the contrary, a long pedicle.

ART. 139.-Three cases of Vesico-Vaginal Fistula. By J. BAKER BROWN, F. R. C. S., Surgeon-Accoucheur to St. Mary's Hospital.

(Medical Times and Gazette, April 17,-1858.)

CASE 1.-Mrs. K, æt. 22. I was called to see this lady by Mr. Kisch, who gave the following history: About six weeks ago she was confined of her first child. The labor was very long and tedious, and the head remained in the pelvis for many hours without making any progress whatever, so at last the forceps were applied, and after a good deal of difficulty the child was abstracted. She progressed without any unfavorable symptom till the sixth day, when she perceived that her urine was constantly escaping, without her being in any way conscious of it, and that it did so in all postures equally. This continued without alteration, although her general health rapidly improved, and she was able to sit up in perfect comfort in every other respect at the usual period.

Upon examination, it was discovered that there was an opening, which would admit a middle sized bougie, situated just at the junction of the bladder with the urethra.

The edges had not become at all callous, but were soft and yielding. Every drop of the urine escaped through this fistula.

February 2d, 1858.-I proceeded to operate, assisted by Dr. Priestly and Messrs. Kisch, Nunn, and Philip Harper. The patient being placed in the usual lithotomy position, and a full-sized wood bougie being introduced into the bladder through the urethra, so as to raise the fistulous opening well into sight, and to give a little support while the edges were being pared, I proceeded to split up the coats of the bladder, first dissecting a narrow strip of mucous membrane from the edges of the fistulous opening, and turning the so dissected edges, without removing them, back into the fistula, thus obtaining a raw surface. Having done this, I inserted three double silk sutures at regular intervals through the split surfaces, and then tied these over two pieces of fine elastic bougie about an inch in length, and by this means the two raw surfaces were brought into close, equal, and exact apposition, and by careful manipulation no portion of mucous membrane was allowed to get between. The parts were then covered with dry lint, and the usual bent catheter, with an India-rubber bag attached, introduced, and left in the bladder.

Two grains of opium were given as soon as the effects of chloroform had a little subsided. The patient continued nursing her baby.

On February 8th I found that the same sutures had cut themselves out; when I syringed the vagina, which I did every day, they came away in the basin. There had been not the slightest escape of urine up to this day. She was therefore allowed to leave off the catheter. In four days-viz., the 12th-she was allowed to pass the urine herself every three hours. In two days she found she could go five, six, or eight hours at night, and then pass it naturally, none escaping involuntarily; but on beginning to dress or suckle the child, some escaped from the urethra, which seemed to come away from want of controlling power. On carefully watching the parts where the fistula was, and requesting her to cough, I could see a drop or two percolate through the united surfaces, just like the escape of perspiration from the pores of the skin. I applied caustic to this part, as the mucous membrane of the vagina had not yet covered over the parts operated on.

Thursday, 18th.-The nurse saw a small escape from the vagina; but from that time till the 22d there had been no escape, except occasionally in the day a drop from the urethra, although the patient walked about the room.

March 2d.-There has been no escape, and, on a most careful examination,